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Despite recent advances in the field, the association between subsyndromal delirium (SSD) in the ICU and poor outcomes is not entirely clear. We performed a retrospective multicentric observational study analyzing mental status during the first 72 h of ICU stay. Of the 681 patients included, SSD occurred in 22.7%. Considering the worst cognitive assessment during the first 72 h, 233 (34%) patients had normal mental status, 124 (18%) patients had SSD and 324 (48%) patients had delirium or coma. SSD was not independently associated with an increased risk of death when compared with normal mental status (OR 95%IC 1.0 vs. 1.35 [0.73–1.49], p = 0.340), but was associated with a longer ICU LOS (7.0 (4–12) vs. 4 (3–8) days, p < 0.001). SSD patients who deteriorated to delirium or coma (21%) had a longer ICU LOS in comparison with those who improved or maintained mental status (8 (5–11) vs. 6 (4–8) days, p = 0.025), but did not have an increase in mortality. The main factors associated with the progression from SSD to delirium or coma were the use of mechanical ventilation, the use of intravenous benzodiazepines and a baseline APACHE II score > 23 points. Our findings support the association of SSD with increased ICU LOS, but not with ICU mortality. Monitoring the trajectory of SSD early at ICU admission can help to identify patients with increased risk of conversion from SSD to delirium or coma.

Purpose Clinical characteristics and management of COVID-19 patients have evolved during the pandemic, potentially changing their outcomes. We analyzed the associations of changes in mortality rates with clinical profiles and respiratory support strategies in COVID-19 critically ill patients. Methods A multicenter cohort of RT-PCR-confirmed COVID-19 patients admitted at 126 Brazilian intensive care units between February 27th and October 28th, 2020. Assessing temporal changes in deaths, we identified distinct time periods. We evaluated the association of characteristics and respiratory support strategies with 60-day in-hospital mortality using random-effects multivariable Cox regression with inverse probability weighting. Results Among the 13,301 confirmed-COVID-19 patients, 60-day in-hospital mortality was 13%. Across four time periods identified, younger patients were progressively more common, non-invasive respiratory support was increasingly used, and the 60-day in-hospital mortality decreased in the last two periods. 4188 patients received advanced respiratory support (non-invasive or invasive), from which 42% underwent only invasive mechanical ventilation, 37% only non-invasive respiratory support and 21% failed non-invasive support and were intubated. After adjusting for organ dysfunction scores and premorbid conditions, we found that younger age, absence of frailty and the use of non-invasive respiratory support (NIRS) as first support strategy were independently associated with improved survival (hazard ratio for NIRS first [95% confidence interval], 0.59 [0.54–0.65], p

Objectives Coronavirus disease 19 (COVID-19) is a major cause of hospital admission and represents a challenge for patient management during intensive care unit (ICU) stay. We aimed to describe the clinical course and outcomes of COVID-19 pneumonia in critically ill patients. Methods We performed a systematic search of peer-reviewed publications in MEDLINE, EMBASE and the Cochrane Library up to 15th August 2020. Preprints and reports were also included if they met the inclusion criteria. Study eligibility criteria were full-text prospective, retrospective or registry-based publications describing outcomes in patients admitted to the ICU for COVID-19, using a validated test. Participants were critically ill patients admitted in the ICU with COVID-19 infection. Results From 32 articles included, a total of 69 093 patients were admitted to the ICU and were evaluated. Most patients included in the studies were male (76 165/128 168, 59%, 26 studies) and the mean patient age was 56 (95%CI 48.5–59.8) years. Studies described high ICU mortality (21 145/65 383, 32.3%, 15 studies). The median length of ICU stay was 9.0 (95%CI 6.5–11.2) days, described in five studies. More than half the patients admitted to the ICU required mechanical ventilation (31 213/53 465, 58%, 23 studies) and among them mortality was very high (27 972/47 632, 59%, six studies). The duration of mechanical ventilation was 8.4 (95%CI 1.6–13.7) days. The main interventions described were the use of non-invasive ventilation, extracorporeal membrane oxygenation, renal replacement therapy and vasopressors. Conclusions This systematic review, including approximately 69 000 ICU patients, demonstrates that COVID-19 infection in critically ill patients is associated with great need for life-sustaining interventions, high mortality, and prolonged length of ICU stay.

PURPOSE OF REVIEW: This review aims to evaluate the evidence and recommendations for the prescription of corticosteroids as adjunctive therapy in patients with severe community-acquired pneumonia. RECENT FINDINGS: Corticosteroids have been prescribed with the objective to attenuate the marked and persistent activation of the immune system. However, some causes of community-acquired pneumonia, namely viral, are associated with unexpected low levels of cytokines and depressed cellular immunity. As a result, several recent randomized controlled trials and large prospective observational studies repeatedly showed that corticosteroids had no impact on survival, and in some types of pneumonia like influenza, its use was associated with potential harmful effects like invasive aspergillosis. Apart from this, adverse effects, namely hyperglycemia, superinfections and increased length-of-stay, were frequent findings in the corticosteroid-treated patients. SUMMARY: According to the current evidence, corticosteroids are recommended in Pneumocystis jiroveci pneumonia in HIV-infected patients and recommendations are against its use in influenza. In all other forms of severe community-acquired pneumonia, with the exclusion of SARS-CoV-2 pneumonia, the strength of the evidence does not support the safe and widespread use of corticosteroids as adjunctive therapy. Further studies are needed to identify subgroups of severe community-acquired pneumonia that can benefit or not from corticosteroids.

Background The COVID-19 pandemic tested the capacity of intensive care units (ICU) to respond to a crisis and demonstrated their fragility. Unsurprisingly, higher than usual mortality rates, lengths of stay (LOS), and ICU-acquired complications occurred during the pandemic. However, worse outcomes were not universal nor constant across ICUs and significant variation in outcomes was reported, demonstrating that some ICUs could adequately manage the surge of COVID-19. Methods In the present editorial, we discuss the concept of a resilient Intensive Care Unit, including which metrics can be used to address the capacity to respond, sustain results and incorporate new practices that lead to improvement. Results We believe that a resiliency analysis adds a component of preparedness to the usual ICU performance evaluation and outcomes metrics to be used during the crisis and in regular times. Conclusions The COVID-19 pandemic demonstrated the need for a resilient health system. Although this concept has been discussed for health systems, it was not tested in intensive care. Future studies should evaluate this concept to improve ICU organization for standard and pandemic times.

Background: Readmissions to Intensive Care Units (ICUs) result in increased morbidity, mortality, and ICU resource utilisation (e.g. prolonged mechanical ventilation), and as such, is a widely utilised metric of quality of critical care. Most of the evidence on incidence, characteristics, associated risk factors and attributable outcomes of unplanned readmission to ICU are from studies performed in high-income countries This study explores the determinants of risk attributable to unplanned ICU readmission in four ICUs in Kathmandu, Nepal. Methods: The registry-embedded eCRF reported data on case mix, severity of illness, in-ICU interventions (including organ support), ICU outcome, and readmission characteristics. Data were captured in all adult patients admitted between September 2019 and February 2021. Population and ICU encounter characteristics were compared between those with and without readmission. Independent risk factors for readmission were assessed using univariate analysis. Results: In total 2955 patients were included in the study. Absolute unplanned ICU readmission rate was 5.69 % (n=168) for all four ICUs. Median time from ICU discharge to readmission was 3 days (IQR=8,1). Of those readmitted, 29.17% (n=49) were discharged at night following their index admission. ICU mortality was higher following readmission to ICU(p=0.016) and mortality was increased further in patients whose primary index discharge was at night(p= 0.019). Primary diagnosis, age, and use of organ support in the first 24hrs of index admission were all independently attributable risk factors for readmission. Conclusions: Unplanned ICU readmission rates were adversely associated with significantly poorer outcomes, increased ICU resource utilisation. Clinical and organisational characteristics influenced risk of readmission and outcome.

Purpose of review Critical care registries are synonymous with measurement of outcomes following critical illness. Their ability to provide longitudinal data to enable benchmarking of outcomes for comparison within units over time, and between units, both regionally and nationally is a key part of the evaluation of quality of care and ICU performance as well as a better understanding of case-mix. This review aims to summarize literature on outcome measures currently being reported in registries internationally, describe the current strengths and challenges with interpreting existing outcomes and highlight areas where registries may help improve implementation and interpretation of both existing and new outcome measures. Recent findings Outcomes being widely reported through ICU registries include measures of survival, events of interest, patient-reported outcomes and measures of resource utilization (including cost). Despite its increasing adoption, challenges with quality of reporting of outcomes measures remain. Measures of short-term survival are feasible but those requiring longer follow-ups are increasingly difficult to interpret given the evolving nature of critical care in the context of acute and chronic disease management. Furthermore, heterogeneity in patient populations and in healthcare organisations in different settings makes use of outcome measures for international benchmarking at best complex, requiring substantial advances in their definitions and implementation to support those seeking to improve patient care. Summary Digital registries could help overcome some of the current challenges with implementing and interpreting ICU outcome data through standardization of reporting and harmonization of data. In addition, ICU registries could be instrumental in enabling data for feedback as part of improvement in both patient-centred outcomes and in service outcomes; notably resource utilization and efficiency.

Background Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation. Method We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance. Results The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%). Conclusions Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.

Background: Unplanned readmissions to Intensive Care Units (ICUs) result in increased morbidity, mortality, and ICU resource utilisation (e.g. prolonged mechanical ventilation), and as such, is a widely utilised metric of quality of critical care. Most of the evidence on incidence, characteristics, associated risk factors and attributable outcomes of unplanned readmission to ICU are from studies performed in high-income countries This study explores the determinants of risk attributable to unplanned ICU readmission in four ICUs in Kathmandu, Nepal. Methods: The registry-embedded eCRF reported data on case mix, severity of illness, in-ICU interventions (including organ support), ICU outcome, and readmission characteristics. Data were captured in all adult patients admitted between September 2019 and February 2021. Population and ICU encounter characteristics were compared between those with and without readmission. Independent risk factors for readmission were assessed using univariate analysis. Results: In total 2948 patients were included in the study. Absolute unplanned ICU readmission rate was 5.60 % (n=165) for all four ICUs. Median time from ICU discharge to readmission was 3 days (IQR=8,1). Of those readmitted, 29.7% (n=49) were discharged at night following their index admission. ICU mortality was higher following readmission to ICU(p=0.016) and mortality was increased further in patients whose primary index discharge was at night(p= 0.019). Primary diagnosis, age, and use of organ support in the first 24hrs of index admission were all independently attributable risk factors for readmission. Conclusions: Unplanned ICU readmission rates were adversely associated with significantly poorer outcomes, increased ICU resource utilisation. Clinical and organisational characteristics influenced risk of readmission and outcome.

Severity of illness scores are used for benchmarking and assessment of adjusted mortality in intensive care units (ICU). Te Acute Physiology and Chronic Health Evaluation (APACHE) and the Simplifed Acute Physiology Score (SAPS) 3 scores were recently evaluated in ICU patients with coronavirus disease 2019 (COVID-19) with conficting fndings. While in the cohorts from United Kingdom and United States ICU scores underestimated the actual mortality and poorly stratifed disease severity, analyses from Austria using the SAPS-3 with frst-level customization suggested satisfactory performance. In this study, we aimed to evaluate the performance of SAPS-3 to predict hospital mortality in a large cohort of COVID-19 patients admitted to ICUs in Brazil.

Coronavirus disease 19 (COVID-19) has posed unprecedented healthcare system challenges, some of which will lead to transformative change. It is obvious to healthcare workers and policymakers alike that an effective critical care surge response must be nested within the overall care delivery model. The COVID-19 pandemic has highlighted key elements of emergency preparedness. These include having national or regional strategic reserves of personal protective equipment, intensive care unit (ICU) devices, consumables and pharmaceuticals, as well as effective supply chains and efficient utilization protocols. ICUs must also be prepared to accommodate surges of patients and ICU staffing models should allow for fluctuations in demand. Pre-existing ICU triage and end-of-life care principles should be established, implemented and updated. Daily workflow processes should be restructured to include remote connection with multidisciplinary healthcare workers and frequent communication with relatives. The pandemic has also demonstrated the benefits of digital transformation and the value of remote monitoring technologies, such as wireless monitoring. Finally, the pandemic has highlighted the value of pre-existing epidemiological registries and agile randomized controlled platform trials in generating fast, reliable data. The COVID-19 pandemic is a reminder that besides our duty to care, we are committed to improve. By meeting these challenges today, we will be able to provide better care to future patients. ispartof: INTENSIVE CARE MEDICINE vol:47 issue:3 pages:282-291 ispartof: location:United States status: published

The length of stay (LOS) in the intensive care unit (ICU) is one of the most commonly used metrics for quality of care. Despite its potential limitations, ICU LOS is easy to measure, reproducible and can be used as a proxy for resource use, costs, and efficiency.(1) Moreover, it is a patientcentered outcome; therefore, it is of interest to multiple stakeholders, such as patients and families, managers, payors, and ICU personnel. However, in most circumstances, the ICU LOS is used retrospectively to assess ICU efficiency or to understand patients with a long LOS and, thus, elevated costs of care. Therefore, patient LOS prediction at ICU admission could help coordinate care, implement preventive measures, and better communicate with managers, payors, and families, setting realistic expectations.

The extraordinary pace of research on coronavirus disease 2019 (COVID-19) has been one of the major success stories of the pandemic. Therapeutic trials involving thousands of patients, which usually take years to complete, have been reported in a matter of months. National and international registries and networks have reported on tens of thousands of patients in near real time. However, there have also been many challenges: hundreds of trials have been underpowered, duplicated, or of poor quality; excessive bureaucracy has complicated study initiation; and only a small percentage of eligible patients worldwide have been enrolled in studies, while many others have been treated with off-label, unproven therapies. All of this has been complicated by an “infodemic” of low-quality medical information, accelerated by social media. info:eu-repo/semantics/publishedVersion

RESUMO Objetivo: Construir um modelo de custo-efetividade para comparar o uso de propofol com o de midazolam em pacientes críticos adultos sob uso de ventilação mecânica. Métodos: Foi construído um modelo de árvore decisória para pacientes críticos submetidos à ventilação mecânica, o qual foi analisado sob a perspectiva do sistema privado de saúde no Brasil. O horizonte temporal foi o da internação na unidade de terapia intensiva. Os desfechos foram custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e custo-efetividade por hora de ventilação mecânica evitada. Foram obtidos os dados do modelo a partir de metanálise prévia. Assumiu-se que o custo da medicação estava incluído nos custos da unidade de terapia intensiva. Conduziram-se análises univariada e de sensibilidade probabilística. Resultados: Pacientes mecanicamente ventilados em uso de propofol tiveram diminuição de sua permanência na unidade de terapia intensiva e na duração da ventilação mecânica, respectivamente, em 47,97 horas e 21,65 horas. Com o uso de propofol, ocorreu redução média do custo de U$2.998,971 em comparação ao uso do midazolam. A custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e por hora de ventilação mecânica evitada foi dominante, respectivamente, em 94,40% e 80,8% do tempo. Conclusão: Ocorreu diminuição significante do custo associado ao uso de propofol, no que se refere à permanência na unidade de terapia intensiva e à duração da ventilação mecânica para pacientes críticos adultos. ABSTRACT Objective: To build a cost-effectiveness model to compare the use of propofol versus midazolam in critically ill adult patients under mechanical ventilation. Methods: We built a decision tree model for critically ill patients submitted to mechanical ventilation and analyzed it from the Brazilian private health care system perspective. The time horizon was that of intensive care unit hospitalization. The outcomes were cost-effectiveness per hour of intensive care unit stay avoided and cost-effectiveness per hour of mechanical ventilation avoided. We retrieved data for the model from a previous meta-analysis. We assumed that the cost of medication was embedded in the intensive care unit cost. We conducted univariate and probabilistic sensitivity analyses. Results: Mechanically ventilated patients using propofol had their intensive care unit stay and the duration of mechanical ventilation decreased by 47.97 hours and 21.65 hours, respectively. There was an average cost reduction of US$ 2,998.971 for propofol when compared to midazolam. The cost-effectiveness per hour of intensive care unit stay and mechanical ventilation avoided were dominant 94.40% and 80.8% of the time, respectively. Conclusion: There was a significant reduction in costs associated with propofol use related to intensive care unit stay and duration of mechanical ventilation for critically ill adult patients.

International audience; Benchmarking is a common and effective method for measuring and analyzing ICU performance. With the existence of national registries, objective information can now be obtained to allow benchmarking of ICU care within and between countries. The present manuscript briefly describes the current status of benchmarking in healthcare and critical care and presents the LOGIC project, an initiative to promote international benchmarking for intensive care units. Currently 13 registries have joined LOGIC. We showed large differences in the utilization of ICU as well as resources and in outcomes. Despite the need for careful interpretation of differences due to variation in definitions and limited risk adjustment, LOGIC is a growing worldwide initiative that allows access to insightful epidemiologic data from ICUs in multiple databases and registries.

Background: The impact of neutropenia in critically ill immunocompromised patients admitted in a context of acute respiratory failure (ARF) remains uncertain. The primary objective was to assess the prognostic impact of neutropenia on outcomes of these patients. Secondary objective was to assess etiology of ARF according to neutropenia. Methods: We performed a post hoc analysis of a prospective multicenter multinational study from 23 ICUs belonging to the Nine-I network. Between November 2015 and July 2016, all adult immunocompromised patients with ARF admitted to the ICU were included in the study. Adjusted analyses included: (1) a hierarchical model with center as random effect; (2) propensity score (PS) matched cohort; and (3) adjusted analysis in the matched cohort. Results: Overall, 1481 patients were included in this study of which 165 had neutropenia at ICU admission (11%). ARF etiologies distribution was significantly different between neutropenic and non-neutropenic patients, main etiologies being bacterial pneumonia (48% vs 27% in neutropenic and non-neutropenic patients, respectively). Initial oxygenation strategy was standard supplemental oxygen in 755 patients (51%), high-flow nasal oxygen in 165 (11%), non-invasive ventilation in 202 (14%) and invasive mechanical ventilation in 359 (24%). Before adjustment, hospital mortality was significantly higher in neutropenic patients (54% vs 42%; p = 0.006). After adjustment for confounder and center effect, neutropenia was no longer associated with outcome (OR 1.40, 95% CI 0.93–2.11). Similar results were observed after matching (52% vs 46%, respectively; p = 0.35) and after adjustment in the matched cohort (OR 1.04; 95% CI 0.63–1.72). Conclusion: Neutropenia at ICU admission is not associated with hospital mortality in this cohort of critically ill immunocompromised patients admitted for ARF. In neutropenic patients, main ARF etiologies are bacterial and fungal infections., SCOPUS: ar.j, info:eu-repo/semantics/published

The delivery of critical care is a major challenge for developing countries [1]. The inequity of access to an ICU bed, heterogeneous triage policies, a low staff/patient ratio and suboptimal adherence to evidence-based practices contribute to disproportionally high mortality of sepsis and acute respiratory distress syndrome in these countries [2,3,4,5]. In addition, limited step-down and specialized ward beds’ availability further widens the gap between critical and non-critical care inside hospitals. As the COVID-19 pandemic spreads through the world, developing countries are challenged with the surge of pneumonia cases where up to 30% of all hospitalized cases will require ICU admission [6]. In August 2020, Brazil is a hotspot of COVID-19 with more than 100,000 deaths. Other Latin American countries such as Mexico, Peru, Colombia, and Chile are also among the 10 countries with most cases worldwide. Several factors seem to have contributed to the dramatic progress of the epidemic in the country. Initial measures of social distancing were adopted at the beginning of the epidemic in several states. However, the lack of central coordination and, at a certain point, the denial of the pandemic by a populist government meant that more effective measures such as lockdown were not adopted whereas use of unproven therapies such as hydroxychloroquine was encouraged. Also, the low availability of tests and progression towards the interior and peripheries of large cities made the epidemic hard to control causing overwhelming hospitals and ICUs.

Objectives: To test whether differences in both general and sepsis-specific patient characteristics explain the observed differences in sepsis mortality between countries, using two national critical care (ICU) databases. Design: Cohort study. Setting: We analyzed 62 and 164 ICUs in Brazil and England, respectively. Patients: Twenty-two–thousand four-hundred twenty-six adult ICU admissions from January 2013 to December 2013. Interventions: None. Measurements and Main Results: After harmonizing relevant variables, we merged the first ICU episode of adult medical admissions from Brazil (ORganizational CHaractEeriSTics in cRitical cAre study) and England (Intensive Care National Audit & Research Centre Case Mix Programme). Sepsis-3 definition was used, and the primary outcome was hospital mortality. We used multilevel logistic regression models to evaluate the impact of country (Brazil vs England) on mortality, after adjustment for general (age, sex, comorbidities, functional status, admission source, time to admission) and sepsis-specific (site of infection, organ dysfunction type and number) patient characteristics. Of medical ICU admissions, 13.2% (4,505/34,150) in Brazil and 30.7% (17,921/58,316) in England met the sepsis definition. The Brazil cohort was older, had greater prevalence of severe comorbidities and dependency compared with England. Respiratory was the most common infection site in both countries. The most common organ dysfunction was cardiovascular in Brazil (41.2%) and respiratory in England (85.8%). Crude hospital mortality was similar (Brazil 41.4% vs England 39.3%; odds ratio, 1.12 [0.98–1.30]). After adjusting for general patient characteristics, there was an important change in the point-estimate of the odds ratio (0.88 [0.75–1.02]). However, after adjusting for sepsis-specific patient characteristics, the direction of effect reversed again with Brazil having higher risk-adjusted mortality (odds ratio, 1.22 [1.05–1.43]). Conclusions: Patients with sepsis admitted to ICUs in Brazil and England have important differences in general and sepsis-specific characteristics, from source of admission to organ dysfunctions. We show that comparing crude mortality from sepsis patients admitted to the ICU between countries, as currently performed, is not reliable and that the adjustment for both general and sepsis-specific patient characteristics is essential for valid international comparisons of mortality amongst sepsis patients admitted to critical care units. Drs. Rowan and Soares are senior authors. † In memoriam. The views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service, the National Institute for Health Research or the Department of Health. Drs. Ranzani and Shankar-Hari are equal contributors. Dr. Ranzani did data analyses. Drs. Ranzani and Shankar-Hari wrote the first draft of the article. Drs. Harrison, Rabello, Salluh, Rowan, and Soares led data collection. Dr. Rabello died during the peer-review process of this article. All authors unanimously agreed on her fundamental contribution for this study. All authors conceptualized and designed the study, interpreted data, and critically revised the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). The original ORganizational CHaractEeriSTics in cRitical cAre study was supported by the National Council for Scientific and Technological Development (Grant number 304240/2014-1), Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro and by departmental funds from the D’Or Institute for Research and Education. The Case Mix Programme is a subscription-based, national quality assessment program. The current study was funded internally by Intensive Care National Audit & Research Centre. The funding sources had no role in the design, conduct or analyses of the study. Dr. Shankar-Hari is supported by the National Institute for Health Research Clinician Scientist Award (NIHR-CS-2016-16-011). Dr. Soares disclosed that he is founder and equity shareholder at Epimed Solutions. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: otavioranzani@usp.br Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Given the rapidly changing nature of COVID-19, clinicians and policy makers require urgent review and summary of the literature, and synthesis of evidence-based guidelines to inform practice. The WHO advocates for rapid reviews in these circumstances. The purpose of this rapid guideline is to provide recommendations on the organizational management of intensive care units caring for patients with COVID-19 including: planning a crisis surge response; crisis surge response strategies; triage, supporting families, and staff. Electronic supplementary material The online version of this article (10.1007/s00134-020-06092-5) contains supplementary material, which is available to authorized users.

Characteristics of structure and process impact ICU performance and the outcomes of critically ill patients. We sought to identify organizational characteristics associated with efficient ICUs in low-resource settings.This is a secondary analysis of a multicenter cluster-randomized clinical trial in Brazil (CHECKLIST-ICU). Efficient units were defined by standardized mortality ratio (SMR) and standardized resource use (SRU) lower than the overall medians and non-efficient otherwise. We used a regularized logistic regression model to evaluate associations between organizational factors and efficiency.From 118 ICUs (13,635 patients), 47 units were considered efficient and 71 non-efficient. Efficient units presented lower incidence rates (median[IQR]) of central line-associated bloodstream infections (4.95[0.00-22.0] vs 6.29[0.00-25.6], p = .04), utilization rates of mechanical ventilation (0.41[0.07-0.73] vs 0.58[0.19-0.82], p .001), central venous catheter (0.67[0.15-0.98] vs 0.78[0.33-0.98], p = .04), and indwelling urinary catheter (0.62[0.22-0.95] vs 0.76[0.32-0.98], p .01) than non-efficient units. The reported active surveillance of ventilator-associated pneumonia (OR = 1.72; 95%CI, 1.16-2.57) and utilization of central venous catheters (OR = 1.94; 95%CI, 1.32-2.94) were associated with efficient ICUs.In low-resource settings, active surveillance of nosocomial infections and the utilization of invasive devices were associated with efficiency, supporting the management and evaluation of performance indicators as a starting point for improvement in ICU.

Submitted by DSpace Unilasalle (dspace@unilasalle.edu.br) on 2021-09-10T23:12:37Z No. of bitstreams: 1 The role of steroids in severe CAP.pdf: 232136 bytes, checksum: fc65c7581dcec5c29d337042cb681d4c (MD5) Made available in DSpace on 2021-09-10T23:12:37Z (GMT). No. of bitstreams: 1 The role of steroids in severe CAP.pdf: 232136 bytes, checksum: fc65c7581dcec5c29d337042cb681d4c (MD5) Previous issue date: 2020 Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti–inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.

Objectives: To determine the impact of chronic obstructive pulmonary disease (COPD) on incidence, microbiology, and outcomes of ventilator-associated lower respiratory tract infections (VA-LRTI). Methods: Planned ancillary analysis of TAVeM study, including 2960 consecutive adult patients who received invasive mechanical ventilation (MV) &gt, 48 h. COPD patients (n = 494) were compared to non-COPD patients (n = 2466). The diagnosis of ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP) was based on clinical, radiological and quantitative microbiological criteria. Results: No significant difference was found in VAP (12% versus 13%, p = 0.931), or VAT incidence (13% versus 10%, p = 0.093) between COPD and non-COPD patients. Among patients with VA-LRTI, Escherichia coli and Stenotrophomonas maltophilia were significantly more frequent in COPD patients as compared with non-COPD patients. However, COPD had no significant impact on multidrug-resistant bacteria incidence. Appropriate antibiotic treatment was not significantly associated with progression from VAT to VAP among COPD patients who developed VAT, unlike non-COPD patients. Among COPD patients, patients who developed VAT or VAP had significantly longer MV duration (17 days (9&ndash, 30) or 15 (8&ndash, 27) versus 7 (4&ndash, 12), p &lt, 0.001) and intensive care unit (ICU) length of stay (24 (17&ndash, 39) or 21 (14&ndash, 40) versus 12 (8&ndash, 19), p &lt, 0.001) than patients without VA-LRTI. ICU mortality was also higher in COPD patients who developed VAP (44%), but not VAT(38%), as compared to no VA-LRTI (26%, p = 0.006). These worse outcomes associated with VA-LRTI were similar among non-COPD patients. Conclusions: COPD had no significant impact on incidence or outcomes of patients who developed VAP or VAT.

In the last decades, experts and medical societies have strongly recommended the measurement of quality indicators and the assessment of intensive care unit (ICU) performance [1, 2]. This recommendation is based on the concept that measurement will generate transparency of results for multiple stakeholders and be a robust source of targets for quality improvement to be translated into improved clinical outcomes. Apart from the measurement of the results of a single ICU over time, reproducible and risk-adjusted outcomes are used to generate performance comparisons [3] in benchmarking projects for ICUs as employed in hospitals networks and national registries [4]. What’s next for critical care benchmarking? The widespread use of information technology (IT) in healthcare altogether with more sophisticated modeling statistics and newer techniques such as machine learning have potential implications for the next steps in benchmarking (Fig. 1). From the IT perspective, increased interoperability of medical devices, electronic health records (EHRs) and information systems will change the amount and speed of data acquisition and presentation to healthcare professionals, additionally it will expand access to data on processes of care and patient-centered outcomes. Moreover, the widespread use of mobile and wearable devices will allow access to information regarding quality of life, activities of daily living and functional status reported by the patients. In a recent study involving 60,000 ICU admissions, functional capacity prior to ICU admission was not only independently associated with outcomes but also improved the prognostic ability of SAPS3 [5]. Web-based centralized systems and mobile apps will play a major role in this scenario as shown in recent studies of post-hospital follow-ups [6] and survivors of critical illness. This should allow a better evaluation of the effectiveness of ICU care on long-term survival, readmissions, social and labor insertion and cognitive function. Also, as the healthcare systems evolve with the increasing role of long-term acute care facilities, hospices and institutions dedicated to rehabilitation, outcomes such as hospital length of stay may become obsolete for benchmarking. Thus, thinking of a full cycle of an episode of care, outcomes such as “home-to-home” time can be pursued and benchmarked. Open in a separate window Fig. 1 The future of critical care benchmarking

Background: It is unclear whether influenza infection and associated co-infection are associated with patient-important outcomes in critically ill immunocompromised patients with acute respiratory failure. Methods: Preplanned secondary analysis of EFRAIM, a prospective cohort study of 68 hospitals in 16 countries. We included 1611 patients aged 18 years or older with non-AIDS-related immunocompromise, who were admitted to the ICU with acute hypoxemic respiratory failure. The main exposure of interest was influenza infection status. The primary outcome of interest was all-cause hospital mortality, and secondary outcomes ICU length of stay (LOS) and 90-day mortality. Results: Influenza infection status was categorized into four groups: patients with influenza alone (n = 95, 5.8%), patients with influenza plus pulmonary co-infection (n = 58, 3.6%), patients with non-influenza pulmonary infection (n = 820, 50.9%), and patients without pulmonary infection (n = 638, 39.6%). Influenza infection status was associated with a requirement for intubation and with LOS in ICU (P < 0.001). Patients with influenza plus co-infection had the highest rates of intubation and longest ICU LOS. On crude analysis, influenza infection status was associated with ICU mortality (P < 0.001) but not hospital mortality (P = 0.09). Patients with influenza plus co-infection and patients with non-influenza infection alone had similar ICU mortality (41% and 37% respectively) that was higher than patients with influenza alone or those without infection (33% and 26% respectively). A propensity score-matched analysis did not show a difference in hospital mortality attributable to influenza infection (OR = 1.01, 95%CI 0.90-1.13, P = 0.85). Age, severity scores, ARDS, and performance status were all associated with ICU, hospital, and 90-day mortality. Conclusions: Category of infectious etiology of respiratory failure (influenza, non-influenza, influenza plus co-infection, and non-infectious) was associated with ICU but not hospital mortality. In a propensity score-matched analysis, influenza infection was not associated with the primary outcome of hospital mortality. Overall, influenza infection alone may not be an independent risk factor for hospital mortality in immunosuppressed patients., SCOPUS: ar.j, info:eu-repo/semantics/published

For decades, corticosteroids are proposed as adjuvant therapies for severe infections. Despite mounting evidence from randomized controlled trials, there is still an intense debate regarding the role of systemic low-dose corticosteroids as a part of the treatment of septic shock. In the present article, we review the current literature and detail aspects on the pathophysiologic rationale, the current evidence, actual practice, and future directions on this topic.

Purpose To investigate the impact of organizational characteristics and processes of care on hospital mortality and resource use in patients with cancer admitted to intensive care units (ICUs). Patients and Methods We performed a retrospective cohort study of 9,946 patients with cancer (solid, n = 8,956; hematologic, n = 990) admitted to 70 ICUs (51 located in general hospitals and 19 in cancer centers) during 2013. We retrieved patients’ clinical and outcome data from an electronic ICU quality registry. We surveyed ICUs regarding structure, organization, staffing patterns, and processes of care. We used mixed multivariable logistic regression analysis to identify characteristics associated with hospital mortality and efficient resource use in the ICU. Results Median number of patients with cancer per center was 110 (interquartile range, 58 to 154), corresponding to 17.9% of all ICU admissions. ICU and hospital mortality rates were 15.9% and 25.4%, respectively. After adjusting for relevant patient characteristics, presence of clinical pharmacists in the ICU (odds ratio [OR], 0.67; 95% CI, 0.49 to 0.90), number of protocols (OR, 0.92; 95% CI, 0.87 to 0.98), and daily meetings between oncologists and intensivists for care planning (OR, 0.69; 95% CI, 0.52 to 0.91) were associated with lower mortality. Implementation of protocols (OR, 1.52; 95% CI, 1.11 to 2.07) and meetings between oncologists and intensivists (OR, 4.70; 95% CI, 1.15 to 19.22) were also independently associated with more efficient resource use. Neither admission to ICUs in cancer centers compared with general hospitals nor annual case volume had an impact on mortality or resource use. Conclusion Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

Using biomarkers as a guide to tailor the duration of antibiotic treatment in respiratory infections is an attractive hypothesis assessed in several studies. Recent work aiming to summarize the evidence assessed the effect of a procalcitonin (PCT)-guided antibiotic treatment on outcomes in acute lower respiratory tract infections (LRTI), suggesting that significant reductions in antibiotic duration occur when using a PCT-guided algorithm. However, controversial evidence also suggested PCT-guided algorithms were associated with increased antibiotic duration and increased incidence of Clostridium difficile, without any impact on mortality, in real-world settings. So, although using PCT-guided antibiotic stewardship is promising, after more than a decade of randomized controlled trials on this topic the evidence in its favor is still less than compelling due to limitations in trial design, not taking into consideration fundamental aspects of PCT biology, and the absence of evidence-based antimicrobial duration in intervention and control groups. In this commentary we highlight some questions and limitations of primary PCT study data that might impact interpretation and clinical use of PCT at the bedside.

The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.

Background Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals. Methods/design The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (

Background Although light sedation levels are associated with several beneficial outcomes for critically ill patients on mechanical ventilation, the majority of patients are still deeply sedated. Organizational factors may play a role on adherence to light sedation levels. We aimed to identify organizational factors associated with a moderate to light sedation target on the first 48 h of mechanical ventilation, as well as the association between early achievement of within-target sedation and mortality. Methods This study is a secondary analysis of a multicenter two-phase study (prospective cohort followed by a cluster-randomized controlled trial) performed in 118 Brazilian ICUs. We included all critically ill patients who were on mechanical ventilation 48 h after ICU admission. A moderate to light level of sedation or being alert and calm (i.e., the Richmond Agitation-Sedation Scale of − 3 to 0) was the target for all patients on mechanical ventilation during the study period. We collected data on the type of hospital (public, private, profit and private, nonprofit), hospital teaching status, nursing and physician staffing, and presence of sedation, analgesia, and weaning protocols. We used multivariate random-effects regression with ICU and study phase as random-effects and correction for patients’ Simplified Acute Physiology Score 3 and Sequential Organ Failure Assessment. We also performed a mediation analysis to explore whether sedation level was just a mediator of the association between organizational factors and mortality. Results We included 5719 patients. Only 1710 (29.9%) were on target sedation levels on day 2. Board-certified intensivists on the morning and afternoon shifts were associated with an adequate sedation level on day 2 (OR = 2.43; CI 95%, 1.09–5.38). Target sedation levels were associated with reduced hospital mortality (OR = 0.63; CI 95%, 0.55–0.72). Mediation analysis also suggested such an association, but did not suggest a relationship between the physician staffing model and hospital mortality. Conclusions Board-certified intensivists on morning and afternoon shifts were associated with an increased number of patients achieving lighter sedation goals. These findings reinforce the importance of organizational factors, such as intensivists’ presence, as a modifiable quality improvement target. Electronic supplementary material The online version of this article (10.1186/s13054-019-2323-y) contains supplementary material, which is available to authorized users.

Frail patients are known to experience poor outcomes. Nevertheless, we know less about how frailty manifests itself in patients’ physiology during critical illness and how it affects resource use in intensive care units (ICU). We aimed to assess the association of frailty with short-term outcomes and organ support used by critically ill patients. Retrospective analysis of prospective collected data from 93 ICUs in Brazil from 2014 to 2015. We assessed frailty using the modified frailty index (MFI). The primary outcome was in-hospital mortality. Secondary outcomes were discharge home without need for nursing care, ICU and hospital length of stay (LOS), and utilization of ICU organ support and transfusion. We used mixed logistic regression and competing risk models accounting for relevant confounders in outcome analyses. The analysis consisted of 129,680 eligible patients. There were 40,779 (31.4%) non-frail (MFI = 0), 64,407 (49.7%) pre-frail (MFI = 1–2) and 24,494 (18.9%) frail (MFI ≥ 3) patients. After adjusted analysis, frailty was associated with higher in-hospital mortality (OR 2.42, 95% CI 1.89–3.08), particularly in patients admitted with lower SOFA scores. Frail patients were less likely to be discharged home (OR 0.36, 95% CI 0.54–0.79) and had higher hospital and ICU LOS than non-frail patients. Use of all forms of organ support (mechanical ventilation, non-invasive ventilation, vasopressors, dialysis and transfusions) were more common in frail patients and increased as MFI increased. Frailty, as assessed by MFI, was associated with several patient-centered endpoints including not only survival, but also ICU LOS and organ support.

Objective: To assess whether ventilator-associated lower respiratory tract infections (VA-LRTIs) are associated with mortality in critically ill patients with acute respiratory distress syndrome (ARDS). Materials and Methods: Post hoc analysis of prospective cohort study including mechanically ventilated patients from a multicenter prospective observational study (TAVeM study); VA-LRTI was defined as either ventilator-associated tracheobronchitis (VAT) or ventilator-associated pneumonia (VAP) based on clinical criteria and microbiological confirmation. Association between intensive care unit (ICU) mortality in patients having ARDS with and without VA-LRTI was assessed through logistic regression controlling for relevant confounders. Association between VA-LRTI and duration of mechanical ventilation and ICU stay was assessed through competing risk analysis. Contribution of VA-LRTI to a mortality model over time was assessed through sequential random forest models. Results: The cohort included 2960 patients of which 524 fulfilled criteria for ARDS; 21% had VA-LRTI (VAT = 10.3% and VAP = 10.7%). After controlling for illness severity and baseline health status, we could not find an association between VA-LRTI and ICU mortality (odds ratio: 1.07; 95% confidence interval: 0.62-1.83; P = .796); VA-LRTI was also not associated with prolonged ICU length of stay or duration of mechanical ventilation. The relative contribution of VA-LRTI to the random forest mortality model remained constant during time. The attributable VA-LRTI mortality for ARDS was higher than the attributable mortality for VA-LRTI alone. Conclusion: After controlling for relevant confounders, we could not find an association between occurrence of VA-LRTI and ICU mortality in patients with ARDS.

Introduction Higher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients. Methods We included 59 614 patients admitted to 78 ICUs participating during 2013. We defined ‘weekend admission’ as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions. Results A total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P

Background Subsyndromal delirium (SSD) is a frequent condition and has been commonly described as an intermediate stage between delirium and normal cognition. However, the true frequency of SSD and its impact on clinically relevant outcomes in the intensive care unit (ICU) remains unclear. Methods We performed a systematic search in PubMed, Embase, CINAHL, Cochrane Library, and PsychINFO, with no language restrictions, up to 1 October 2016 to identify publications that evaluated SSD in ICU patients. Results The six eligible studies were evaluated. SSD was present in 950 (36%) patients. Four studies evaluated only surgical patients. Four studies used the Intensive Care Delirium Screening Checklist (ICDSC) and two used the Confusion Assessment Method (CAM) score to diagnose SSD. The meta-analysis showed an increased hospital length of stay (LOS) in SSD patients (0.31, 0.12–0.51, p = 0.002; I 2 = 34%). Hospital mortality was described in two studies but it was not significant (hazard ratio 0.97, 0.61–1.55, p = 0.90 and 5% vs 9%, p = 0.05). The use of antipsychotics in SSD patients to prevent delirium was evaluated in two studies but it did not modify ICU LOS (6.5 (4–8) vs 7 (4–9) days, p = 0.66 and 2 (2–3) vs 3 (2–3) days, p = 0.517) or mortality (9 (26.5%) vs 7 (20.6%), p = 0.55). Conclusions SSD occurs in one-third of the ICU patients and has limited impact on the outcomes. The current literature concerning SSD is composed of small-sample studies with methodological differences, impairing a clear conclusion about the association between SSD and progression to delirium or worse ICU clinical outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1765-3) contains supplementary material, which is available to authorized users.

Cited By :1 Export Date: 19 October 2017 Correspondence Address: Nora, D.; NOVA Medical School, New University of Lisbon, Rua Francisco Ferrer, 2-1D, Portugal; email: davidjgarcianora@gmail.com Chemicals/CAS: C reactive protein, 9007-41-4; procalcitonin, 56645-65-9 References: Zilahi, G., Artigas, A., Loeches, I.M., What' s new in multidrug-resistant pathogens in the ICU? (2016) Ann Intensive Care, 6, p. 96; Michael, C.A., Dominey-Howes, D., Labbate, M., The antimicrobial resistance crisis: causes, consequences, and management (2014) Front Public Health, 2, p. 145; Dupuy, A.M., Philippart, F., Péan, Y., Role of biomarkers in the management of antibiotic therapy: an expert panel review: I-currently available biomarkers for clinical use in acute infections (2013) Ann Intensive Care, 3, p. 22; Póvoa, P., Salluh, J.I.F., Biomarker-guided antibiotic therapy in adult critically ill patients: a critical review (2012) Ann Intensive Care, 2, p. 32; Biomarkers and surrogate endpoints: Preferred definitions and conceptual framework (2001) Clin Pharmacol Ther, 69, pp. 89-95; Póvoa, P., Salluh, J.I.F., Use of biomarkers in sepsis: Many questions, few answers (2013) Rev Bras Ter Intensiva, 25, pp. 1-2; Quenot, J.P., Luyt, C.E., Roche, N., Role of biomarkers in the management of antibiotic therapy: an expert panel review II: clinical use of biomarkers for initiation or discontinuation of antibiotic therapy (2013) Ann Intensive Care, 3, p. 21; Markanday, A., Acute Phase Reactants in Infections: Evidence-Based Review and a Guide for Clinicians Anurag (2015) Open Forum Infect Dis, 2; Cho, S.-Y., Choi, J.-H.J., Biomarkers of sepsis (2014) Infect Chemother, 46, pp. 1-12; van der Does, Y., Limper, M., Schuit, S.C.E., Higher diagnostic accuracy and cost-effectiveness using procalcitonin in the treatment of emergency medicine patients with fever (The HiTEMP study): a multicenter randomized study (2016) BMC Emerg Med, 16, p. 17; Downes, K.J., Weiss, S.L., Gerber, J.S., A Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: The Optimizing Antibiotic Strategies in Sepsis (OASIS) Study (2016) J Pediatric Infect Dis Soc, , [Epub ahead of print]; Ehl, S., Gering, B., Bartmann, P., C-Reactive Protein Is a Useful Marker for Guiding Duration of Antibiotic Therapy in Suspected Neonatal Bacterial Infection (1997) Pediatrics, 99, pp. 216-221; Bomela, H.N., Ballot, D.E., Cory, B.J., Use of C-reactive protein to guide duration of empiric antibiotic therapy in suspected early neonatal sepsis (2000) Pediatr Infect Dis J, 19, pp. 531-535; Huddy, J.R., Ni, M.Z., Barlow, J., Point-of-care C reactive protein for the diagnosis of lower respiratory tract infection in NHS primary care: a qualitative study of barriers and facilitators to adoption (2016) BMJ Open, 6; Cals, J.W.L., Butler, C.C., Hopstaken, R.M., Effect of point of care testing for C reactive protein and (2009) BMJ, 338; Strykowski, D.F., Nielsena, A.B.S., Llorb, C., An intervention with access to C-reactive protein rapid test reduces antibiotic overprescribing in acute exacerbations of chronic bronchitis and COPD (2015) Fam Pract, 32, pp. 395-400; Huang, Y., Chen, R., Wu, T., Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: A systematic review and meta-analysis of primary care studies (2013) Br J Gen Pract, 63, pp. e787-e794; Little, P., Stuart, B., Francis, N., Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: A multinational, cluster, randomised, factorial, controlled trial (2013) Lancet, 382, pp. 1175-1182; Aabenhus, R., Jensen, J.U., Jørgensen, K.J., Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care (2014) Cochrane Database Syst Rev, (11); Oppong, R., Jit, M., Smith, R.D., Cost-effectiveness of point-of-care C-reactive protein testing to inform antibiotic prescribing decisions (2013) Br J Gen Pract, 63, pp. e465-e471; Hunter, R., Cost-Effectiveness of Point-of-Care C-Reactive Protein Tests for Respiratory Tract Infection in Primary Care in England (2015) Adv Ther, 32, pp. 69-85; Kiaei, B.A., Ghiasi, F., Moradi, D., Precalcitonin and C-reactive protein as markers in response to antibiotic treatment in ventilator-associated pneumonia in intensive care unit-hospitalized patients (2015) Adv Biomed Res, 4, p. 240; Oliveira, C.F., Botoni, F.A., Oliveira, C.R., Procalcitonin versus C-reactive protein for guiding antibiotic therapy in sepsis: a randomized trial (2013) Crit Care Med, 41, pp. 2336-2343; Christ-Crain, M., Opal, S.M., Clinical review: the role of biomarkers in the diagnosis and management of community-acquired pneumonia (2010) Crit Care, 14, p. 203; Sager, R., Kutz, A., Mueller, B., Procalcitonin-guided diagnosis and antibiotic stewardship revisited (2017) BMC Med, 15, p. 15; Schuetz, P., Albrich, W., Mueller, B., Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future (2011) BMC Med, 9, p. 107; Schuetz, P., Albrich, W., Christ-Crain, M., Procalcitonin for guidance of antibiotic therapy (2010) Expert Rev Anti Infect Ther, 8, pp. 575-587; Schuetz, P., Chiappa, V., Briel, M., Procalcitonin Algorithms for Antibiotic Therapy Decisions (2011) Arch Intern Med, 171, pp. 1322-1331; Schuetz, P., Müller, B., Stolz, D., Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections (2012) Cochrane Database Syst Rev, 9; Lin, C., Pang, Q., Meta-analysis and systematic review of procalcitonin-guided treatment in acute exacerbation of chronic obstructive pulmonary disease (2016) Clin Respir J, , [Epub ahead of print]; Andriolo, B.N., Andriolo, R., Salomão, R., Effectiveness and safety of procalcitonin evaluation for reducing mortality in adult patients with sepsis, severe sepsis and septic shock (2017) Cochrane Database Syst Rev, (1); Layios, N., Lambermont, B., Canivet, J.-L., Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients (2012) Crit Care Med, 40, pp. 2304-2309; Bouadma, L., Luyt, C., Tubach, F., Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial (2010) Lancet, 375, pp. 463-474; Jensen, J.U., Hein, L., Lundgren, B., Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial (2011) Crit Care Med, 39, pp. 2048-2058; Jensen, J.U., Heslet, L., Jensen, T.H., Procalcitonin increase in early identification of critically ill patients at high risk of mortality (2006) Crit Care Med, 34, pp. 2596-2602; de Jong, E., van Oers, J.A., Beishuizen, A., Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial (2016) Lancet Infect Dis, 16, pp. 819-827; Chastre, J., Wolff, M., Fagon, J.Y., Comparison of 8 vs 15 Days of Antibiotic Therapy for Ventilator-Associated Pneumonia in Adults-A Randomized Trial (2003) JAMA, 290, pp. 2588-2598; Pugh, R., Grant, C., Rpd, C., Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults (Review) (2015) Cochrane Database Syst Rev, (8); Shehabi, Y., Sterba, M., Garrett, P.M., Procalcitonin Algorithm in Critically Ill Adults with Undifferentiated Infection or Suspected Sepsis A Randomized Controlled Trial (2014) Am J Respir Crit Care Med, 190, pp. 1102-1110; Annane, D., Maxime, V., Faller, J.P., Procalcitonin levels to guide antibiotic therapy in adults with non-microbiologically proven apparent severe sepsis: a randomised controlled trial (2013) BMJ Open, 3; Deliberato, R.O., Marra, A.R., Sanches, P.R., Clinical and economic impact of procalcitonin to shorten antimicrobial therapy in septic patients with proven bacterial infection in an intensive care setting (2013) Diagn Microbiol Infect Dis, 76, pp. 266-271; Hochreiter, M., Köhler, T., Schweiger, A.M., Procalcitonin to guide duration of antibiotic therapy in intensive care patients: a randomized prospective controlled trial (2009) Crit Care, 13; Stolz, D., Smyrnios, N., Eggimann, P., Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study (2009) Eur Respir J, 34, pp. 1364-1375; Schroeder, S., Hochreiter, M., Koehler, T., Procalcitonin (PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis: Results of a prospective randomized study (2009) Langenbecks Arch Surg, 394, pp. 221-226; Nobre, V., Harbarth, S., Graf, J.-D., Use of Procalcitonin to Shorten Antibiotic Treatment Duration in Septic Patients (2008) Am J Respir Crit Care Med, 177, pp. 498-505; Svoboda, P., Kantorová, I., Scheer, P., Can procalcitonin help us in timing of re-intervention in septic patients after multiple trauma or major surgery? (2007) Hepatogastroenterology, 54, pp. 359-363; Rhodes, A., Evans, L.E., Alhazzani, W., Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 (2017) Intensive Care Med, 43, pp. 304-377; Kalil, A.C., Metersky, M.L., Klompas, M., Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society (2016) Clin Infect Dis, 63, pp. e61-e111; Westwood, M., Ramaekers, B., Whiting, P., Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis (2015) Health Technol Assess, 19, pp. v-xxv and 1-236; Canovi, M., Lucchetti, J., Stravalaci, M., A new surface plasmon resonance-based immunoassay for rapid, reproducible and sensitive quantification of pentraxin-3 in human plasma (2014) Sensors, 14, pp. 10864-10875; Hansen, M.B., Rasmussen, L.S., Garred, P., Pentraxin-3 as a marker of disease severity and risk of death in patients with necrotizing soft tissue infections: a nationwide, prospective, observational study (2016) Crit Care, 20, p. 40; Póvoa, P., Salluh, J.I.F., Nobre, V., Martín-Loeches, I., Biomarker guided antibiotic therapy (2016) What's new? ICU Manag Pract, (1), pp. 24-28 Biomarkers as C-reactive protein (CRP) and procalcitonin (PCT) emerged as tools to help clinicians to diagnose infection and to properly initiate and define the duration of antibiotic therapy. Several randomized controlled trials, including adult critically ill patients, showed that PCT-guided antibiotic stewardship was repeatedly associated with a decrease in the duration of antibiotic therapy with no apparent harm. There are however some relevant limitations in these trials namely the low rate of compliance of PCT-guided algorithms, the high rate of exclusion (without including common clinical situations and pathogens) and the long duration of antibiotic therapy in control groups. Such limitations weakened the real impact of such algorithms in the clinical decision-making process and strengthened the concept that the initiation and the duration of antibiotic therapy cannot depend solely on a biomarker. Future efforts should address these limitations in order to better clarify the role of biomarkers on the complex and multifactorial issue of antibiotic management and to deeply understand its potential effect on mortality. © Annals of Translational Medicine. All rights reserved. publishersversion published

Contains fulltext : 182587.pdf (Publisher’s version ) (Closed access) Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-code status or for time-limited trials, increased survival and quality of life in ICU survivors, changing prognostic factors, early ICU admission for optimal monitoring, and use of noninvasive diagnostic and therapeutic strategies. In this review, experts in the management of critically ill cancer patients highlight recent changes in the use and the results of intensive care in patients with malignancies. They seek to put forward a standard of care for the management of these patients and highlight important updates that are required to care for them. The research agenda they suggest includes important studies to be conducted in the next few years to increase our understanding of organ dysfunction in this population and to improve our ability to appropriately use life-saving therapies or select new therapeutic approaches that are likely to improve outcomes. This review aims to provide more guidance for the daily management of patients with cancer, in whom outcomes are constantly improving, as is our global ability to fight against what is becoming the leading cause of mortality in industrialized and non-industrialized countries.